Care Coordination and Health Homes. Barbara Lantz Manager, Medicaid Managed Care Washington Health Care Authority

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1 Care Coordination and Health Homes Barbara Lantz Manager, Medicaid Managed Care Washington Health Care Authority October 16, 2013

2 Care Coordination Overview Continuity of Care Identification of Special Health Needs Clients Care Coordination Special Populations Coordination: Transitional Care Skilled Nursing Facility Children in Foster Care Mental Health Services 2

3 Why Care Coordination? Greater number of special needs populations Research demonstrated efficacy Isn t just about having insurance Better coordination and orchestration of services for chronically ill makes sense 3

4 Continuity of Care Assure continuity for those in active course of treatment Elements Preservation of provider-enrollee relationships Prescription continuity during transitions Allow enrollees to continue to receive care from non-participating providers 4

5 Identification of Individuals with Special Needs Within 90 days of enrollment, identify individuals with special needs Administrative data, e.g., PRISM Chronic conditions Indicator of high risk pregnancy Foster care, SSI designation Social Complexity Enrollees with unmet care needs Responses to surveys/interviews 5

6 Initial Health Screen Initial health screen required of: New, family connect, and reconnect (greater than 6 month period of disenrollment) Requirement to report performance on screens according to contract schedule Future (July ) assignments of new individuals based on screening performance 6

7 Initial Health Assessment Differentiates those eligible; and not eligible for HH, but still have special needs Health Home PRISM score 1.5 or greater; at least 1 chronic condition Special Needs Through identification process and required screening separate activities Evaluation of physical and behavioral health status, health and social service history 7

8 Care Coordinator Activities Care Coordination Plan Enrollee self-management goals Short and long-term treatment goals Identification of gaps/barriers and how these were addressed Timely follow-up of the enrollee Progress on self-management goals Consultation and coordination with providers 8

9 SPECIAL POPULATIONS COORDINATION 9

10 Transitional Care Transitional services must be provided to enrollees Operational agreements in place and describe responsibility of each party List of activities to reduce re-hospitalization much from Coleman model 10

11 Skilled Nursing Facility Plan responsibility for first 29 days any cause Coordinate with: SNF for discharge planning ALTSA Home and Community Based Services for custodial care assessment If client eligible for custodial care, disenrolled If discharged to home or community residential setting, remains enrolled 11

12 Children in Foster Care Coordination with Fostering Well-Being Program Medically Fragile Children Moving forward with RFP for Foster Children Plan release in January 12

13 Mental Health Services Operating agreements with PIHPs (RSNs) Specify exchange of information Transitions of care Procedures to determine enrollee s eligibility for RSN services 13

14 Other. Internal quality assurance Screening requirements added ACES Direct access to specialty providers 14

15 HEALTH HOMES 15

16 Health Homes Overview Health Action Plan (HAP) Assignment of a Care Coordinator HAP Reassessment Wrap Up 16

17 Overview Reserved for highest risk, highest cost individuals Intended to be community-based It is not primarily a telephonic care coordination program Capitalizes on existing community resources to serve as care coordinators The enrollee is at the center of the intervention 17

18 Health Action Plan Centerpiece of the program Client is encouraged to identify health action goals Coached and supported in self-management of chronic conditions Informed by critical assessment of existing data resources, e.g., PRISM Use of standardized screening instruments 18

19 Assignment of a Care Coordinator Use of a smart assignment process Assignment to a Care Coordination Organization Following HAP: Continued interactions with enrollee Foster communication between providers Problem-solving issues of concern to enrollee Help enrollee navigate care systems Accompany enrollee to critical appointments 19

20 HAP Reassessment Update screens every 4 months Reassess progress towards goals every 6 months Provide individual and family support Referral to community and social supports 20

21 Wrap Up Enrollees cannot be discharged from HH They can be placed in lower-level intervention category They can choose to opt out and opt back in They may need a lot of encouragement to participate We believe it is a value-added program for Washington Apple Health enrollees 21

22 Questions? Barbara Lantz Manager, Quality and Care Management Phone:

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